Provider Demographics
NPI:1750978359
Name:SMITH DENTAL CARE OF WINDER LLC
Entity type:Organization
Organization Name:SMITH DENTAL CARE OF WINDER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-376-2345
Mailing Address - Street 1:3700 ATLANTA HWY STE 10
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-7201
Mailing Address - Country:US
Mailing Address - Phone:706-619-1307
Mailing Address - Fax:706-510-2594
Practice Address - Street 1:48 PIEDMONT DR STE 302
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-8132
Practice Address - Country:US
Practice Address - Phone:706-619-1307
Practice Address - Fax:706-510-2594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty